аспирин при ХСН, показан или нет?
 

Коллеги, помогите , пожалуйста разобраться. Нужно ли назначать аспирин в профилактических дозах при ХСН. Например, если это ИБС, то тут есть четкие рекомендации и доказательная база. А как правильно поступить с кардиомиопатией ( дилятационная, аритмогенная и.т.д) легочным сердцем или миокардиофиброзом особенно в сочетании с нарушениями ритма? Есть мнения, что аспирин негативно влияет на прогноз при ХСН, или я не прав. У нас с зав.отделением мнения разошлись... Сразу оговорюсь, что речь идет о случаях , когда нет комплаенса для назначения варфарина.

Вопрос "вечный".

Может быть можно поступить следующим образом:
1. Использование SCORE. Больше равно 5% - аспирин назначать
2. Наличие сердечно-сосудистой болезни: ИБС, атеросклероз артерий головного мозга, атеросклероз артерий нижних конечностей - аспирин назначать
3. Любая форма фибрилляции предесердий - аспирин или варфарин или и то и другое, это все хорошо описано.
4. АГ старше 50 лет - аспирин показан
5. Сахарный диабет старше 40 лет - аспирин показан.
Если все это учитывать, то вполне возможно вопрос и разрешится само собой. Например, мало я видел ЗКМП без фибрилляции предсердий.

Antiplatelet agents
The positive role of antiplatelet therapy, mainly aspirin, in preventing atherothrombotic events in different groups of patients with various vascular risks, including patients with CHF, has been suggested by the results of a large meta-analysis, the Antithrombotic Trialists' Collaboration [66], although there is criticism of these findings [67].

Some of the trials investigating the benefits of angiotensin-converting enzyme (ACE) inhibitors in CHF patients have reported unfavorable effects of concomitant use of aspirin. The SOLVD found that survival was not improved with aspirin administration in the group of patients concomitantly receiving enalapril [55]. In the CONSENSUS II, patients on a combination of aspirin and enalapril had a significantly increased mortality rate in comparison to those patients who received enalapril only, but not aspirin [68]. The most common pathophysiologic explanation of the possible adverse interactions between aspirin and ACE inhibitors is the counteraction between their effects on the production of vasodilating prostaglandins [69]. Despite being plausible, the adverse clinical interactions between aspirin and ACE inhibitors have not been demonstrated so far in a robust clinical study. Nevertheless, the most recent guidelines of the European Society of Cardiology on CHF management state that 'there is little evidence to support the concomitant treatment with an ACE inhibitor and aspirin in heart failure' [70]. Probably, more clinical studies are needed to resolve this question. In the meantime, the wider use of clopidogrel (an antiplatelet agent with a different mechanism of action from aspirin) may circumvent the anticipated problems with aspirin for CHF patients receiving ACE inhibitors. A large randomized trial has reported that clopidogrel is at least as safe, and more effective, than aspirin in the secondary prevention of strokes, recurrent coronary events and cardiovascular deaths in a variety of patients with different clinical presentations of atherosclerosis, including patients with CHF [71]. No prospective study has been conducted to specifically evaluate clopidogrel or other antiplatelet agents (such as dipyridamol) in patient with CHF, so routine administration of these medications remains at the discretion of the attending physician.

In this respect, the evidence for the benefits of antiplatelet therapy for CHF patents is even less conclusive than it is for VKA anticoagulation. Considering the high incidence of atherosclerotic disease as a cause or comorbid condition in CHF, it is anticipated that future studies will address this question. In the meantime, the practical guidelines on the management of CHF [65,70,72] recommend aspirin administration only for the purposes of secondary prevention of atherothrombotic events and for patients with atrial fibrillation in situations when warfarin is contraindicated. Special attention should be paid to the facts that patients with CHF, compared to the general population, appear to be more prone to major gastrointestinal bleeding and renal impairment with aspirin use, and that these complications of aspirin therapy are dose-dependent.
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Antithrombotic therapy in patients with chronic heart failure: rationale, clinical evidence and practical implications.